Reform's Mixed Impact on Immigrants

At first glance, the Affordable Care Act's implications for immigrants seem obvious. The legislation benefits legal immigrants and leaves out the undocumented. As of 2014, it provides legal immigrants with subsidies to purchase insurance, requiring them, like other Americans, to maintain coverage and offering them access to state insurance exchanges. But the law denies undocumented immigrants any subsidies or even the use of the exchanges to buy insurance with their own money.

The full story, though, is more complicated. The act leaves in place a five-year waiting period for legal immigrants to qualify for Medicaid and the Children's Health Insurance Program. As a result, though they will be able to use the exchanges to purchase subsidized coverage, many recently arrived legal immigrants with incomes below or near the poverty line are likely to remain uninsured for want of resources to pay their share of the costs.

Yet because the act provides substantially increased aid to community health centers, it may help many immigrants -- both legal and undocumented -- receive medical care even without insurance.

And because the law includes requirements for citizenship verification for anyone using the exchanges, it may also have unexpected, indirect effects on the administration of insurance for immigrants and non-immigrants alike.

The impact of these provisions will depend on how the federal and state governments implement the law. Language barriers are a major factor in immigrants' access to health coverage and health care. Depending on the level of community outreach, the legislation could affect Hispanic and other immigrants in significantly different ways.

***

According to a 2009 Kaiser Family Foundation report, one in four people without health insurance in the United States is an immigrant. Legal immigrants will therefore be among the major beneficiaries of the new subsidies to make insurance affordable. Anticipating those benefits as well as the increased aid for community health centers, Hispanic representatives in Congress voted overwhelmingly for the Affordable Care Act.

But immigrant-rights advocates are disappointed by the legislation's failure to eliminate the five-year waiting period for legal immigrants' eligibility for Medicaid and CHIP. In 2009, when Congress reauthorized CHIP, it gave states the option of covering pregnant women and children who, as recent immigrants, would otherwise be deemed ineligible. To date, only 18 states and the District of Columbia have taken up that option.

The new health-reform act will both raise and reduce coverage of undocumented immigrants beginning in 2014. Unlike legal immigrants, the undocumented will not be required to have insurance, nor will they qualify for premium tax credits or cost-sharing subsidies. Many American-born children of undocumented immigrants will undoubtedly pay a price for their parents' exclusion and fail to be enrolled. "Confusion around the new law is certainly going to prevent many of the 4 million citizen children of undocumented immigrants from receiving coverage for which they are eligible," says Jennifer Ng'andu, deputy director of the Health Policy Project at the National Council of La Raza.

Some undocumented immigrants may receive health coverage because their employers decide to comply with the employer-responsibility provisions of the law. Because they work disproportionately for small businesses that are exempt from the law's requirements, however, the undocumented aren't likely to see substantial gains. In fact, when firms that have provided health insurance in the past begin purchasing it through the exchanges, their undocumented workers could lose coverage they previously had.

One benefit of the legislation for low-income immigrants is unambiguous. Currently, many undocumented as well as legal immigrants receive medical care from federally financed community health centers. Beginning in 2011, the Affordable Care Act appropriates $12.5 billion over five years to expand both the health centers and the National Health Service Corps, which helps provide these centers with physicians. This support, which is projected to double the number of patients served by the centers, will strengthen one of the main sources of primary care in immigrant communities.

***

The requirements for citizenship verification by the new health-insurance exchanges could have a paradoxical effect on immigrants' eligibility for health programs. Although some observers fear that the verification requirements would reduce access, they may in fact increase it.

Until 2005, a signed declaration was sufficient to establish citizenship for federal programs. That year's Deficit Reduction Act, however, established documentation requirements that gave rise to a complicated, four-tiered system of original documents for verifying citizenship. According to a 2007 report by the House Committee on Oversight and Government Reform, the verification procedure came at huge administrative costs and led to significant delays in as well as denials of Medicaid and CHIP coverage for eligible applicants.

To deal with those problems, the legislation reauthorizing CHIP in 2009 gave states the option of using a data match with the Social Security Administration (SSA) to verify applicants' citizenship. Twenty-four states have adopted the new system, or are testing it and will likely adopt it, and the results have been "tremendously positive," says Judy Solomon, co-director of health policy at the Center on Budget and Policy Priorities. According to a recent report by the center, the new procedure has reduced delays and administrative costs for Medicaid and CHIP enrollment. Solomon rejects the idea that citizenship verification was ever justified, but she regards the SSA data match as the lesser of two evils, a way to meet the verification requirement without an "unnecessary" documentation burden.

The Affordable Care Act specifies the SSA data match as the procedure for verifying citizenship in the new exchanges. People subject to citizenship verification for the first time may run into trouble when purchasing health insurance through the exchanges. But, according to Julia Paradise, associate director of the Kaiser Commission on Medicaid and the Uninsured, the required use of the SSA data match may force the hand of the 26 states that still rely on the older, more burdensome documentation system. The result, Solomon and Paradise agree, could be facilitated access to Medicaid and CHIP for eligible applicants who would otherwise face the four-tiered system.

***

The Affordable Care Act could have one final, unexpected effect. According to Steven Camarota, director of research at the conservative Center for Immigration Studies, health reform reduces the likelihood of immigration reform because it significantly increases the fiscal cost of amnesty. "The bottom line is you can't give 11 million more people subsidized health insurance without incurring a whole lot of cost," he says.

Other analysts point out that undocumented immigrants pay federal taxes but remain ineligible for most government-sponsored health programs. "I think it's a fairness question," says Adam Gurvitch, policy analyst at the National Immigration Law Center. "They contribute, but they don't receive any benefits."

Of course, no one can possibly know whether concerns about the cost of the new health-insurance subsidies will be decisive for immigration reform. Many other effects of health reform are similarly unclear because they depend on political responses to fiscal pressures. For example, state governments may respond to tight budgets by cutting community outreach for Medicaid and other programs, thereby reducing enrollment. Because they often face language barriers, immigrants are particularly vulnerable to such cutbacks. If immigrant communities are to benefit from health reform, they will need strong advocacy by all who serve them -- from health-care workers on the front lines to representatives in Congress -- to ensure that reform is carried out with their interests in mind.